NUR 2502 / NUR2502
Final Exam
1. A patient with a spinal cord injury at T6 develops a sudden headache, flushed face,
and BP 210/110 mm Hg. What is the priority nursing intervention?
A. Administer hydralazine IV
B. Place the patient supine and notify the provider
C. Sit the patient upright and check for bladder distention
D. Increase IV fluids
Answer: C – This is autonomic dysreflexia; the first action is to sit the patient up to
lower BP and assess for a noxious stimulus such as bladder distention.
2. Which assessment finding is most concerning in a patient with a basilar skull
fracture?
A. Clear drainage from the nose
B. Periorbital ecchymosis
C. Headache
D. Nausea
Answer: A – Clear nasal drainage may indicate CSF leak; test for glucose and report
immediately to prevent meningitis.
3. A patient is post-stroke with right-sided weakness and expressive aphasia. Which
intervention is most appropriate for communication?
A. Speak loudly and repeat until understood
,B. Use yes/no questions and allow extra time for responses
C. Provide written instructions only
D. Avoid conversation to reduce frustration
Answer: B – Yes/no questions and patience facilitate communication in expressive
aphasia.
Sensory Alterations
4. After cataract surgery, which statement by the patient indicates a need for further
teaching?
A. "I should avoid bending over to tie my shoes."
B. "I can lift my 20-pound grandchild after a few days."
C. "I will wear an eye shield while sleeping."
D. "I should report any sudden pain or vision changes."
Answer: B – Lifting >5 lbs increases intraocular pressure and should be avoided until
cleared by the provider.
5. A patient with Ménière’s disease is at highest risk for which nursing diagnosis?
A. Impaired verbal communication
B. Risk for injury
C. Ineffective airway clearance
D. Impaired swallowing
Answer: B – Vertigo episodes increase fall risk.
Endocrine Disorders
6. Which finding in a patient with Addison’s disease requires immediate
intervention?
A. Fatigue and bronze skin
B. Nausea and muscle weakness
C. BP 78/40 mm Hg and confusion
, D. Craving for salty foods
Answer: C – This suggests Addisonian crisis, requiring rapid fluid replacement and
corticosteroids.
7. The nurse is teaching a patient with new-onset type 1 diabetes about insulin
administration. Which statement needs correction?
A. "I can mix regular insulin with NPH in the same syringe."
B. "I’ll draw up the cloudy insulin first, then the clear insulin."
C. "I’ll rotate injection sites to prevent lipodystrophy."
D. "If I’m sick, I’ll check my blood sugar more often."
Answer: B – The correct order is clear (regular) before cloudy (NPH).
Immune Disorders
8. A patient receiving chemotherapy has an absolute neutrophil count (ANC) of 400.
Which is the priority teaching point?
A. Avoid large crowds and sick contacts
B. Increase high-protein foods
C. Perform weight-bearing exercise daily
D. Limit fluid intake
Answer: A – ANC <500 indicates severe neutropenia; infection prevention is the
priority.
9. Which vaccine is contraindicated in a patient with HIV and CD4 count <200?
A. Influenza (inactivated)
B. Pneumococcal polysaccharide
C. Varicella (live attenuated)
D. Hepatitis B recombinant
Answer: C – Live vaccines are avoided in severe immunosuppression.
Final Exam
1. A patient with a spinal cord injury at T6 develops a sudden headache, flushed face,
and BP 210/110 mm Hg. What is the priority nursing intervention?
A. Administer hydralazine IV
B. Place the patient supine and notify the provider
C. Sit the patient upright and check for bladder distention
D. Increase IV fluids
Answer: C – This is autonomic dysreflexia; the first action is to sit the patient up to
lower BP and assess for a noxious stimulus such as bladder distention.
2. Which assessment finding is most concerning in a patient with a basilar skull
fracture?
A. Clear drainage from the nose
B. Periorbital ecchymosis
C. Headache
D. Nausea
Answer: A – Clear nasal drainage may indicate CSF leak; test for glucose and report
immediately to prevent meningitis.
3. A patient is post-stroke with right-sided weakness and expressive aphasia. Which
intervention is most appropriate for communication?
A. Speak loudly and repeat until understood
,B. Use yes/no questions and allow extra time for responses
C. Provide written instructions only
D. Avoid conversation to reduce frustration
Answer: B – Yes/no questions and patience facilitate communication in expressive
aphasia.
Sensory Alterations
4. After cataract surgery, which statement by the patient indicates a need for further
teaching?
A. "I should avoid bending over to tie my shoes."
B. "I can lift my 20-pound grandchild after a few days."
C. "I will wear an eye shield while sleeping."
D. "I should report any sudden pain or vision changes."
Answer: B – Lifting >5 lbs increases intraocular pressure and should be avoided until
cleared by the provider.
5. A patient with Ménière’s disease is at highest risk for which nursing diagnosis?
A. Impaired verbal communication
B. Risk for injury
C. Ineffective airway clearance
D. Impaired swallowing
Answer: B – Vertigo episodes increase fall risk.
Endocrine Disorders
6. Which finding in a patient with Addison’s disease requires immediate
intervention?
A. Fatigue and bronze skin
B. Nausea and muscle weakness
C. BP 78/40 mm Hg and confusion
, D. Craving for salty foods
Answer: C – This suggests Addisonian crisis, requiring rapid fluid replacement and
corticosteroids.
7. The nurse is teaching a patient with new-onset type 1 diabetes about insulin
administration. Which statement needs correction?
A. "I can mix regular insulin with NPH in the same syringe."
B. "I’ll draw up the cloudy insulin first, then the clear insulin."
C. "I’ll rotate injection sites to prevent lipodystrophy."
D. "If I’m sick, I’ll check my blood sugar more often."
Answer: B – The correct order is clear (regular) before cloudy (NPH).
Immune Disorders
8. A patient receiving chemotherapy has an absolute neutrophil count (ANC) of 400.
Which is the priority teaching point?
A. Avoid large crowds and sick contacts
B. Increase high-protein foods
C. Perform weight-bearing exercise daily
D. Limit fluid intake
Answer: A – ANC <500 indicates severe neutropenia; infection prevention is the
priority.
9. Which vaccine is contraindicated in a patient with HIV and CD4 count <200?
A. Influenza (inactivated)
B. Pneumococcal polysaccharide
C. Varicella (live attenuated)
D. Hepatitis B recombinant
Answer: C – Live vaccines are avoided in severe immunosuppression.
